Knowledge, attitude, and practice of patients with major depressive disorder on exercise therapy

Background This study aimed to explore the knowledge, attitude, and practice (KAP) toward exercise therapy of patients with major depressive disorder (MDD). Methods This cross-sectional study was conducted at the First Hospital of Shanxi Medical University between April and October 2023 in patients with MDD. A self-designed questionnaire was used to evaluate the KAP (Cronbach’s α = 0.787). The minimum-maximum scores were 2–23 for knowledge, 11–55 for attitude, and 7–35 for practice. Results A total of 494 valid questionnaires were analyzed. The mean KAP dimension scores were 15.39 ± 3.34/23 (66.91%), 36.54 ± 19.33/55 (66.44%), and 19.33 ± 5.22/35 (55.23%), indicating poor knowledge, negative attitude, and weak practice. Multivariable logistic regression analysis showed that female (OR = 0.613, 95%CI: 0.376-1.000, P = 0.050), urban residence (OR = 0.443, 95%CI: 0.259–0.758, P = 0.003), suburban residence (OR = 0.047, 95%CI: 0.016–0.138, P < 0.001), higher income (OR = 3.889–7.928, all P < 0.001), and unclear self-reported depression level (OR = 0.078, 95%CI: 0.027–0.221, P < 0.001) were independently associated with the knowledge scores. Knowledge scores (OR = 1.102, 95%CI: 1.022–1.188, P = 0.011), female gender (OR = 0.437, 95%CI: 0.246–0.776, P = 0.005), city (OR = 0.410, 95%CI: 0.226–0.744, P = 0.003), married (OR = 3.577, 95%CI: 1.751–7.650, P < 0.001), higher income (OR = 0.065–0.392, both P < 0.050), depressive trend (OR = 2.640, 95%CI: 1.110–6.278, P = 0.028), high depression score level (OR = 0.176, 95%CI: 0.104-0.300, P < 0.001), and unclear self-reported depression score (OR = 0.023, 95%CI: 0.007–0.076, P < 0.001) were independently associated with the attitude scores. Finally, knowledge scores (OR = 1.130, 95%CI: 1.051–1.215, P = 0.001), attitude scores (OR = 1.199, 95%CI: 1.124–1.280, P < 0.001), and city (OR = 0.583, 95%CI: 0.352–0.965, P = 0.036) were independently associated with the practice scores. The structural equation modeling analysis showed that knowledge, but not attitude (β = 0.103, P = 0.092) or practice (β = 0.034, P = 0.603), influenced the depression level (β=-0.074, P < 0.001); attitude influenced practice (β = 0.369, P < 0.001). Conclusion The KAP toward exercise among MDD patients is poor in Shanxi. Females, people living in urban or suburban areas, with lower income, and self-reported unclear depression levels should be targeted by education interventions.


Background
Major depressive disorder (MDD) is a common and wellresearched type of depressive disorder characterized by persistent low mood, lack of positive affect, and loss of interest in usually pleasurable activities (anhedonia) that is different from the patient's usual self and causes significant distress or impairment for ≥ 2 weeks [1][2][3].MDD is a leading cause of mental health-related disease burden and disability worldwide, affecting an estimated 280 million people [3,4].The reported risk factors for MDD include a family or personal history of major depression and/or substance abuse, chronic medical illness, alcohol and substance use, stressful life events including loss (including bereavement or divorce), major life changes such as job change or financial difficulty, domestic abuse or violence, female sex, low income and unemployment, and disability [2,3].The prognosis of MDD is variable.It is unremitting in about 15% of patients and recurrent in about 35%, with the risk of recurrence increasing with each additional episode of MDD [2,3].It is important to find an effective method to treat and prevent the recurrence of MDD.
Although MDD is often treated with antidepressants and/or psychotherapy [1][2][3], other treatments have attracted increasing attention in recent years.In particular, physical exercise may be beneficial for depressive symptoms and could have effects comparable to antidepressant drugs [5][6][7].Indeed, exercise might improve MDD symptoms compared with no treatment and have similar efficacy as cognitive therapy or sertraline in adults [8].Various studies revealed that resistance exercise training may reduce depressive symptoms in adults [9], exercise interventions are associated with improved depressive symptoms in patients with neurologic disorders [10], and exercise is associated with improvement in depressive symptoms in sedentary patients with chronic illnesses [11].The effect appears to be observed in mildto-moderate MDD [12] but could be less noticeable in severe MDD [13].Furthermore, low exercise tolerance can be considered a marker of depressive symptoms [14].Still, exercise appears not to be associated with long-term improvement in MDD in adults beyond the end of intervention [15] and should, therefore, be performed regularly to maintain the benefits.
Even though exercise can be performed in groups or under the supervision of a kinesiologist or a trainer, exercising is based on self-management, influenced by the patient's knowledge and perception of the benefits and the willingness to exercise [16].Some studies focused on the knowledge and attitude of MDD patients on exercise intervention therapy [16][17][18].A study revealed that general practitioners are generally willing to prescribe exercise to MDD patients [19].Knowledge, attitude, and practice (KAP) studies provide quantitative and qualitative data about a particular subject in a specific population [20,21].They are particularly useful in identifying the knowledge gaps, misconceptions, and misunderstandings that can hinder the optimal performance of the subject and help design educational interventions [20,21].Therefore, this study aimed to examine the KAP of patients with MDD on exercise intervention therapy.

Study design and participants
This cross-sectional study was conducted at the First Hospital of Shanxi Medical University between April 2023 and October 2023 and enrolled patients with MDD.The participants were invited to participate in the study if they were outpatients or inpatients diagnosed with MDD by clinicians, in strict accordance with the MDD criteria for ICD-10.The inclusion criteria were (1) 18-65 years of age, (2) met the diagnostic criteria of the International Classification of Diseases, tenth edition (ICD-10) F32 for depressive episodes, and (3) educational level of primary school or above.The exclusion criteria were (1) diagnosis of other physical and psychiatric disorders, (2) difficulty in reading and writing, or (3) severe suicidal ideation and behavior in the last 2 weeks.This study was approved by the First Medical Ethics Committee of Shanxi Medical University.All participants signed the informed consent form before completing the questionnaire.

Questionnaire
This questionnaire was designed based on the literature [5][6][7][8][9][10][11]22].The first draft of the questionnaire was revised according to the opinions of five senior experts.A pilot evaluation (35 copies) was performed and showed a Cronbach's α of 0.787.
The final questionnaire was in Chinese and included four aspects: demographic data (age, marital status, place of residence, educational level, gender, income, type of medical insurance, depression trend, current therapies received, self-reported depression level, and ways to learn about depression), knowledge dimension (depression and its pathogenesis, prevention, clinical symptoms, and management), attitude dimension, and practice dimension.The knowledge dimension included 10 questions.One point was scored for correct answers, and zero points for other answers.Items K5-K7 included several subitems, and one point was scored for correct answers.The total scores of items K5-K7 were 5, 6, and 5 points, respectively.The score range was 2-23 points.The attitude dimension consisted of 11 questions using a 5-point Likert scale from very positive (5 points) to very negative (1 point).The score range was 11-55 points.The practice dimension consisted of 10 questions using a 5-point Likert scale from always (5 points) to never (1 point).The score range was 7-35 points.
The questionnaires were distributed to the participants at the outpatient clinic and wards of the First Hospital of Shanxi Medical University using posters.The participants could scan the QR code to gain access to a description of the study, consent form, and questionnaire.Members of the research team were also available to answer questions via telephone, email, or WeChat.Questionnaires that took < 1 min to complete, with obvious logical errors, or completed using the same option (e.g., all first choices) were considered invalid.In order to avoid repetition, IP restriction was applied, thus making sure that the survey could only be completed once from a single IP address.A total score of each dimension ≥ 70% was defined as adequate knowledge, positive attitude, and proactive practice [23].

Statistical analysis
The sample size for this study was calculated based on the guideline of having 10 times the number of questionnaire items [24], which, in this study, was 31 independent variables.Therefore, the minimum sample size required was 310 participants.A minimum of 389 participants was required to accommodate a potential 20% non-valid questionnaire rate in survey responses.
Stata 17.0 (Stata Corporation, College Station, TX, USA) was used for statistical analysis.The demographic data and KAP scores of the participants were analyzed descriptively using means ± standard deviations (SD) for continuous data and n (%) for categorical data.Continuous data with a normal distribution were analyzed using Student's t-test (comparison of two groups) or ANOVA (comparison of three or more groups).Continuous data with a skewed distribution were analyzed using the Wilcoxon-Mann-Whitney test (comparison of two groups) or the Kruskal-Wallis analysis of variance (comparison of three or more groups).The categorical data were analyzed using the chi-squared test.Pearson correlation analysis was used to evaluate the correlation among KAP dimensions.Multivariable regression analyses were carried out with the attitude and practice scores as dependent variables to analyze the relationship between demographic data or knowledge or attitude and practice.The mean score of each dimension was used as the cutoff point [25,26].Variables with P < 0.05 in univariable analyses were included in the multivariable analyses.Structural equation modeling (SEM) was used to examine the relationships among the KAP dimensions and other factors.Two-sided P-values < 0.05 were considered statistically significant.

Knowledge
The mean knowledge score was 15.39 ± 3.34 on a maximum of 23 (66.91%).Higher knowledge scores were observed in urban residents (P < 0.001), with higher income (P < 0.001), with a depressive trend (P < 0.001), and with lower depression scores (P < 0.001) (Table 1).The knowledge item with the highest score was K1 (96.96%; "Depression is a mental illness"), while the item with the lowest score was K3 (5.26%; "Most depression treatments focus on preventing its recurrence") (Table 2).

Correlations
The knowledge scores were not correlated to the attitude (r = 0.076, P = 0.093) or practice (r = 0.086, P = 0.057) scores.The attitude scores were correlated to the practice scores (r = 0.394, P < 0.001).

Discussion
Patients with MDD in Shanxi have poor knowledge about exercise as a way to treat MDD, they have a negative attitude toward exercise, and they do not exercise.Being female, living in urban or suburban, with a lower income, and unclear self-reported depression levels have negative impacts on the KAP about exercise as a way to treat MDD.The results may help optimize the performance of exercise therapy in depressive patients.
Most participants were female, consistent with the higher prevalence of MDD among females [2,3].Most participants were unmarried and with a middle-low income, consistent with the association of MDD with low income and relationship difficulties [2,3].Exercise is recognized to improve the symptoms of MDD and have an impact on the risk of recurrence [10,11,22], but exercise must be practiced regularly to have a lasting effect [15].Exercising requires time, and patient self-management is crucial in the quantity and quality of exercise performed by an individual [27,28].Hence, a proper knowledge of the potential benefits of exercise on physical and mental health could improve the attitudes and practice toward exercise among patients with MDD.In the present study, the participants had a generally good grasp of the symptoms, risk factors, and management of MDD but a lower knowledge of the prognosis of MDD, the impact of treatments on recurrence, drug side effects, and the impact of exercise on managing MDD.Patient education interventions should be designed and implemented to improve these points.Lower knowledge was also observed in females, people living in urban or suburban, low income, and an unclear self-reported depression level.Socioeconomic status is often associated with better health literacy [29], as observed here.On the other hand, living in a city can be associated with a more stressful life and less access to parks and sports facilities, leading to a lower willingness to gain knowledge on exercise with fewer opportunities to practice it.Not knowing their depressive status can suggest disinterest in one's health and related knowledge.Females usually have a higher health literacy than males [30], but the higher rate and severity of MDD in females than in males could bias the association of knowledge.The SEM analysis indeed suggests that the depression level influenced knowledge.
Knowledge was associated with attitude and practice, and attitude was associated with practice, as supported by the KAP theory that stipulates that knowledge is the basis for changes in habits while attitudes are the driving force of the changes [20,21].The low attitude and practice observed in the city support the above theory about poor access to sports and activity facilities.The inverse relationship between income and attitudes could be related to the workload and responsibilities and less time and willingness to exercise.The SEM analysis also showed that the depression level affected practice, probably because of a lower willingness to exercise.
Previous data on the KAP toward exercise in patients with MDD are scarce.Doyle et al. [16] reported that 31%, 29%, and 26% of the participants in the United Emirates did not believe that exercise could improve well-being, manage depression, and manage stress/anxiety, respectively.However, a study in Portugal showed that 87.8% of the participants believed that exercise could reduce depressive symptoms [17].A study in South Korea showed that an exercise program could improve the KAP about exercise and MDD [18].Hence, efforts should be taken to improve the KAP toward exercise and MDD, especially among patients with MDD.
This study has limitations.It was performed at a single hospital, limiting the sample size and the geographical source of the participants and, hence, generalizability.The study was advertised on posters, and the participants had to scan the QR code, leading to volunteer and nonresponse biases.The questionnaire was self-designed by the investigators and might be biased by local practices, guidelines, and policies.Still, KAP questionnaires are

Conclusions
In conclusion, patients with MDD in Shanxi have poor knowledge about exercise as a way to treat MDD, they have a negative attitude toward exercise, and they do not exercise.Being female, living in urban or suburban, with a lower income, and unclear self-reported depression levels have negative impacts on the KAP about exercise as a way to treat depression.Future studies should examine the KAP toward exercise in relation to the actual level of physical activity and the depression outcomes in depressive patients.

Table 1
Characteristics of the participants

Table 2
Knowledge dimension

Table 3
Attitude dimension

Table 4
Practice dimension

Table 5
Univariable and multivariable analyses of knowledge, attitude, and practice

Table 5
[31,32]ued)usually developed by local investigators based on local practices, policies, and customs.Otherwise, the questionnaire might miss or misinterpret local realities.It limits the generalizability of the results and the exportability of the questionnaire.A cross-sectional KAP study cannot provide data about cause-to-effect relationships and provide a snapshot of the situation at a precise point in time.Nevertheless, the results could eventually be used as a historical baseline to evaluate the impact of future interventions.The study included several self-reported variables, which are susceptible to recall bias.A SEM analysis was used to examine the relationships among KAP dimensions and other variables, but it is an artificial construct based on predefined hypotheses, and it cannot be used to determine causality with certainty.Finally, all KAP studies are at risk of the social desirability bias, in which some participants can answer what they should do (based on a socially acceptable opinion or behavior) instead of what they really do[31,32].Additional studies are necessary to refine our understanding of the KAP toward exercise among depressive patients nationwide.

Table 6
Parameters of the structural equation modeling